Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection on the 29 September 2015. Overall the practice is rated as good.
Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.
Our key findings across all the areas we inspected were as follows
- Data showed patient outcomes were above average.
- Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
- Patients’ needs were assessed and care was planned and delivered following best practice guidance.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- Information about services and how to complain was available and easy to understand.
- The practice had good facilities and was well equipped to treat patients and meet their needs.
- There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
However, there were areas of practice where the provider needs to make improvements. Although risks to patients who used services were assessed, the systems and processes to address these risks were not always implemented well enough to ensure patients were kept safe.
- We noted that some areas of the premises and equipment had not been sufficiently cleaned. Although vaccine fridge temperatures were monitored, there was no record of any action taken on two occasions when the recommended range was exceeded.
- Some staff were overdue refresher training in safeguarding and no staff had received training at the practice in chaperoning duties. The practice informed us during the process for checking the factual accuracy of the draft inspection report that safeguarding training had been booked for December 2015 and that chaperone training had been provided in November 2015.
- The practice’s emergency equipment was not suitably located and stored and not all staff knew where it was kept.
Although some clinical audits had been carried out, these had not been repeated to monitor improvement in performance to improve patient outcomes. Emergency appointments were available on the day they were requested, but some patients said that they sometimes had to wait a long time for non-urgent appointments.
Importantly, the provider must
- Ensure that all areas of the premises and equipment are suitably cleaned.
- Ensure that staff are aware of the action to take if the vaccine fridge exceeds the recommended temperature range.
In addition, the provider should
- Ensure that staff receive training appropriate to their roles and any further training needs are identified and planned.
- Review the location and storage of emergency equipment and ensure that all staff know its whereabouts.
- Ensure clinical audit cycles are completed to help monitor the service and identify where improvements may be made.
- Continue to work on improving the appointments system so that patients have appropriate access to the service.
Professor Steve Field
CBE FRCP FFPH FRCGP
Chief Inspector of General Practice